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THE NISONGER CHILD BEHAVIOR RATING FORM PARENT VERSION
Child's Name:
Child's Date of Birth:
/ month
Rater's Name:
Date of Rating:
/ month
Relation of Rater to Child:
/ day
year
/ day
year
parent [1] other [9]: (please specify)
I. Please describe any special circumstances or mediating factors that may have affected the child's behavior in the recent past (the last month or two) or prevented you from making complete ratings.
II. POSITIVE SOCIAL. Please describe the child's behavior as it was at home over the last month. IN THE LAST MONTH, THIS CHILD HAS: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Accepted redirection Expressed ideas clearly Followed rules Initiated positive interactions Participated in group activities Resisted provocation, was tolerant Shared with or helped others Stayed on task Was cheerful or happy Was patient, able to delay
Not True [0]
Somewhat or Sometimes True [1]
Very or Often True [2]
Completely or Always True [3]
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PAGE 1
(OVER)
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Nisonger CBRF: Parent
III. PROBLEM BEHAVIOR. For each item that describes the child's behavior as it was over the last month, circle the: 0.... if the behavior did not occur or was not a problem 1.... if the behavior occurred occasionally or was a mild problem 2.... if the behavior occurred quite often or was a moderate problem 3.... if the behavior occurred a lot or was a severe problem
For each problem that occurred, circle only the score that best describes the behavior. PLEASE DO NOT SKIP ANY QUESTIONS. IF YOU DO NOT KNOW THE ANSWER OR HAVE NOT HAD A CHANCE TO OBSERVE THE CHILD FOR A GIVEN TIME, CIRCLE THE ZERO. 1. Apathetic or unmotivated . . . . . . . . . . . . . . . 2. Argues with parents, teachers, or other adults . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Clings to adults, too dependent . . . . . . . . . . . 4. Cruelty or meanness to others . . . . . . . . . . . . 5. Crying, tearful episodes . . . . . . . . . . . . . . . . . 6. Hits or slaps own head, neck, hands, or other body parts . . . . . . . . . . . . . . . . . . . . . 7. Defiant, challenges adult authority . . . . . . . . 8. Knowingly destroys property . . . . . . . . . . . . 9. Difficulty concentrating . . . . . . . . . . . . . . . . . 10. Disobedient . . . . . . . . . . . . . . . . . . . . . . . . . . 11. Rocks body or head back and forth repetitively . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. Doesn't feel guilty after misbehaving . . . . . . 13. Easily distracted . . . . . . . . . . . . . . . . . . . . . . . 14. Easily frustrated . . . . . . . . . . . . . . . . . . . . . . . 15. Overly sensitive; feelings easily hurt . . . . . . . 16. Exaggerates abilities or achievements . . . . . . 17. Explosive, easily angered . . . . . . . . . . . . . . . 18. Has rituals such as head rolling or floor pacing . . . . . . . . . . . . . . . . . . . . . . . . . . 19. Fails to finish things he/she starts . . . . . . . . . 20. Feelings easily hurt . . . . . . . . . . . . . . . . . . . . 21. Feels others are against him/her . . . . . . . . . . 22. Harms self by scratching skin or pulling hair . . . . . . . . . . . . . . . . . . . . . . . . . . 23. Feels worthless or inferior . . . . . . . . . . . . . . . 24. Fidgets, wiggles, or squirms . . . . . . . . . . . . . 25. Shy around others; bashful . . . . . . . . . . . . . . 26. Gets in physical fights . . . . . . . . . . . . . . . . . . 27. Irritable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28. Repeatedly flaps or waves hands, fingers or objects (such as pieces of string) . . . . . . . . 29. Isolates self from others . . . . . . . . . . . . . . . . . 30. Lying or cheating . . . . . . . . . . . . . . . . . . . . . . 31. Nervous or tense . . . . . . . . . . . . . . . . . . . . . . 32. Gouges self, puts things in ears, nose, etc., or eats inedible things . . . . . . . . . . . . . . 33. Overactive, doesn't sit still . . . . . . . . . . . . . . .
0
1 2 3
0 0 0 0
1 1 1 1
2 2 2 2
3 3 3 3
34. 35. 36. 37. 38. 39. 40.
0 0 0 0 0
1 1 1 1 1
2 2 2 2 2
3 3 3 3 3
0 0 0 0 0 0 0
1 1 1 1 1 1 1
2 2 2 2 2 2 2
3 3 3 3 3 3 3
44. 45.
0 0 0 0
1 1 1 1
2 2 2 2
3 3 3 3
50. 51. 52. 53.
0 0 0 0 0 0
1 1 1 1 1 1
2 2 2 2 2 2
3 3 3 3 3 3
54.
0 0 0 0
1 1 1 1
2 2 2 2
3 3 3 3
0 0
1 2 3 1 2 3
41. 42. 43.
46. 47. 48. 49.
55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66.
Overly anxious to please others . . . . . . . . . . . Overly excited, exuberant . . . . . . . . . . . . . . . Physically attacks people . . . . . . . . . . . . . . . . Refuses to talk . . . . . . . . . . . . . . . . . . . . . . . . Repeats the same sound, word, or phrase over and over . . . . . . . . . . . . . . . . . . . Restless, high energy level . . . . . . . . . . . . . . Runs away from adults, teachers, or other authority figures . . . . . . . . . . . . . . . . . . Says no one likes him/her . . . . . . . . . . . . . . . Secretive, keeps things to self . . . . . . . . . . . . Repeatedly bites self hard enough to leave tooth marks or break skin . . . . . . . . . . . Self-conscious or easily embarrassed . . . . . . Shifts rapidly from topic to topic when talking . . . . . . . . . . . . . . . . . . . . . . . . . Short attention span . . . . . . . . . . . . . . . . . . . . Shy or timid behavior . . . . . . . . . . . . . . . . . . Steals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Odd repetitive behaviors (e.g., stares, grimaces, rigid postures) . . . . . . . . . . . . . . . . Stubborn, has to do things own way . . . . . . . Sudden changes in mood . . . . . . . . . . . . . . . . Sulks, is silent and moody . . . . . . . . . . . . . . . Physically harms or hurts self on purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Talks back to teacher, parents, or other adults . . . . . . . . . . . . . . . . . . . . . . . . . . Talks too much or too loud . . . . . . . . . . . . . . Temper tantrums . . . . . . . . . . . . . . . . . . . . . . Threatens people . . . . . . . . . . . . . . . . . . . . . . Threatens to harm self . . . . . . . . . . . . . . . . . . Engages in meaningless, repetitive body movements . . . . . . . . . . . . . . . . . . . . . . Too fearful or anxious . . . . . . . . . . . . . . . . . . Underactive, slow . . . . . . . . . . . . . . . . . . . . . Unhappy or sad . . . . . . . . . . . . . . . . . . . . . . . Violates rules . . . . . . . . . . . . . . . . . . . . . . . . . Withdrawn, uninvolved with others . . . . . . . Worrying . . . . . . . . . . . . . . . . . . . . . . . . . . . . Argues with other children or peers . . . . . . . .
PAGE 2 Developed by M. G. Aman, M. J. Tassé, J. Rojahn, and D. Hammer, 1995.
0 0 0 0
1 1 1 1
2 2 2 2
3 3 3 3
0 0
1 2 1 2
3 3
0 0 0
1 2 1 2 1 2
3 3 3
0 0
1 2 1 2
3 3
0 0 0 0
1 1 1 1
2 2 2 2
3 3 3 3
0 0 0 0
1 1 1 1
2 2 2 2
3 3 3 3
0
1 2
3
0 0 0 0 0
1 1 1 1 1
2 2 2 2 2
3 3 3 3 3
0 0 0 0 0 0 0 0
1 1 1 1 1 1 1 1
2 2 2 2 2 2 2 2
3 3 3 3 3 3 3 3
